Three hours after a burn injury that consisted of circumferential, third -degree burns at the wrist and elbow of the right arm, a patient loses sensation to light touch in his fingers. Motor function of his digits, however, remains intact. The most appropriate treatment for this patient now would consist of:
Third-degree burn injuries are characterized by almost complete loss of elasticity of the skin. Thus, as soft tissue swelling progresses, neurovascular compromise may occur. Failure to recognize this problem may result in the loss of distal extremities. The most reliable signs of decreased peripheral blood flow in burned patients are slow capillary refill as observed in the nail beds, the onset of neurologic deficits, and decreased or absent Doppler ultrasonic pulse detection. When vascular impairment is diagnosed, immediate escharotomies are indicated. Anesthesia is not required for escharotomy-the burn area is insensate because skin nerve endings are destroyed by third-degree burns.
What is the fluid requirement of a 50-kg man with firstdegree burns to his left arm and leg, circumferential second-degree burn to his right arm, and third-degree burns to his torso and right leg.
What is the rate of initial fluid resuscitation?
The most commonly used formula, the Parkland or Baxter formula, consists of 3 to 4 mL/kg/% burn of lactated Ringer solution, of which half is given during the first 8 hours postburn, and the remaining half over the subsequent 16 hours. The concept behind continuous fluid requirements is simple. The burn (and/or inhalation injury) drives an inflammatory response that leads to capillary leak; as plasma leaks into the extravascular space, crystalloid administration maintains the intravascular volume. Therefore, if a patient receives a large fluid bolus in a prehospital setting or emergency department that fluid has likely leaked into the interstitium and the patient still requires ongoing burn resuscitation according to the estimates. Continuation of fluid volumes should depend on the time since injury, urine output, and mean arterial pressure. As the leak closes, the patient will require less volume to maintain these two resuscitation end points.
A patient with a 90% burn encompassing the entire torso develops an increasing Pco2 and peak inspiratory pressure.
Which of the following is most likely to resolve this problem?
The adequacy of respiration must be monitored continuously throughout the resuscitation period. Early respiratory distress may be due to the compromise of ventilation caused by chest wall inelasticity related to a deep circumferential burn wound of the thorax. Pressures required for ventilation increase and arterial Pco2 rises. Inhalation injury, pneumothorax, or other causes can also result in respiratory distress and should be appropriately treated.
Thoracic escharotomy is seldom required, even with a circumferential chest wall burn. When required, escharotomies are performed bilaterally in the anterior axillary lines. If there is significant extension of the burn onto the adjacent abdominal wall, the escharotomy incisions should be extended to this area by a transverse incision along the costal margins.
Which of the following is FALSE regarding silver sulfadiazine?
Silver sulfadiazine is one of the most widely used in clinical practice. Silver sulfadiazine has a wide range of antimicrobial activity, primarily as prophylaxis against burn wound infections rather than treatment of existing infections. It has the added benefits of being inexpensive and easily applied, and has soothing qualities. It is not significantly absorbed systemically and thus has minimal metabolic derangements. Silver sulfadiazine has a reputation for causing neutropenia, but this association is more likely due to neutrophil margination from the inflammatory response. True allergic reactions to the sulfa component of silver sulfadiazine are rare, and at-risk patients can have a small test patch applied to identify a burning sensation or rash. Silver sulfadiazine destroys skin grafts and is contraindicated on burns or donor sites in proximity to newly grafted areas. Also, silver sulfadiazine may retard epithelial migration in healing partial thickness wounds.
Successful antibiotic penetration of a burn eschar can be achieved with:
Mafenide acetate is the antibiotic agent that penetrates burn eschar to reach the interface with the patient's viable tissue. This agent has the disadvantages that it is quite painful on any partial thickness areas, and it is a carbonic anhydrase inhibitor that interferes with renal buffering mechanisms. Chloride is retained, and metabolic acidosis results. For these reasons, silver sulfadiazine is more commonly used in burn centers unless a major problem with burn wound sepsis is present.
Click to expand